The bottom-up allocation approach focuses on the cost of providing a package of essential services in a typical district in each of the 33 provinces of Indonesia. To investigate the impact of different district contexts on the costs of SPM, the condition specific sheets were linked to demographic (age and sex), epidemiological (proportion of the population suffering each disease) and location data (distance between health centres and hospitals for referral). A user friendly interface to enter data and undertake simulations was constructed based on user forms in Visual Basic.
The modelling incorporated a representation of a typical district structure. In Indonesia, public services are usually organised around one (sometimes more) district hospitals and sub-district based health centres (Puskesmas). Health centres are of two main types: those with beds primarily for emergency obstetric care, and those without beds. The health centre acts as a focal point for other public services in the sub-district including sub-health centres, village health posts and services of village midwives. The latter have been an important part of the government’s strategy to expand use of skilled delivery care since the early 1990s . These services are incorporated as part of the Puskesmas network for costing.
The total allocation for s
SPM services in district/province i
is given as
is the proportion of the total population (target group) that potentially may require the service j, d
is the proportion of the target group that are expected to present with the condition and n
is the proportion with the disease that require treatment at a medical facility. The latter reflects the fact that for some conditions treatment is not required or can be provided at home without recourse to medical facilities. Unit costs (c) for service j are assumed to vary across districts and provinces (i):
are respectively the unit cost of primary, hospital care without admission and hospital care with admission for service j in district i; π
is the proportion requiring referral for hospital treatment, m
is the proportion of referrals requiring admission and r
is the average cost of referral from primary to hospital facilities in district i. The cost of care varies by region because of differences in fixed costs, variations in the health system and differences in whether health centres provide inpatient care. The unit cost of drugs, medical supplies and direct staffing are established normatively and are assumed not to vary across the country. Base information for the proportion of target groups with particular conditions was taken from the Department of Health’s regular survey and the most recent Demographic and Health Survey [17, 18].
The cost of primary and hospital care are composed of variable (v) elements such as drugs, laboratory tests and supplies; direct staffing (s) required in the delivery of the specific service by midwives, nurses and midwives; and fixed overhead costs (f) arising from the operational, capital and indirect staffing (administration, clinical support departments and ancillary staff) of each facility or cluster of facilities.:
Treatment normatives for particular diseases are assumed to be similar so that the variable and direct staffing inputs are the same. The variable (v) and direct staffing (s) elements of the cost of each SPM condition were derived through a process of consultation with programme directors in the Ministry of Health and clinicians working within facilities. For variable items this involved listing the drugs and medical supplies required in the treatment of each condition together with quantities required and the probability of a typical patient with the condition requiring the item. For direct staffing, it involved quantifying the time spent by key health staff (general doctors, specialists such as obstetricians, midwives and nurses) with each patient during an episode of illness. To aid this process staff time was listed by key activity area such as time during admission, in the operating theatre, each day on the ward and at discharge. Costs were entered on series of sheets adapted from the Core Plus costing framework and WHO Mother and Baby Package [20, 21]. Costing involved a number of iterations since estimates of staff time were thought to be exaggerated and were revised after preliminary total costs were produced. Resource requirements are based on best local clinical practice for each condition.
Fixed overhead costs are permitted to vary across districts as they are directly related to the number of facilities that are required to serve a given population. Facility numbers are influenced by geography and topology so that a sparsely populated mountainous district will require, ceteris paribus, a larger number of facilities to serve population need. Similarly, while it is assumed that the proportion of patients with disease j requiring referral is similar across districts, the cost of referral (r) is influenced by proximity to referral facilities and so will vary across districts.
The costing incorporates three types of fixed overhead:
Facility overheads (health centre or district hospital), including administrative and support staff, operating costs of the facility and (annualised) capital
SPM overheads attributable to particular SPM services (e.g. spraying for dengue, surveillance for infectious diseases) which vary on a population basis rather than according to patients treated. These services are largely provided through the DHO and the costs are apportioned to each facility and the service as part of the modelling.
Administrative overheads associated with running the DHO
We include all the costs of treatment whether provided at hospital, health centre or in the community. The costing of the health centre (puskesmas) incorporates the costs of subordinated facilities such as sub-centres and village health posts.
The service-based SPMs are largely limited to communicable diseases plus maternal care. Much of the disease burden, for example from non-communicable diseases and trauma, is excluded. Although not directly costed, the model recognises the economies of scope of providing for these other diseases by incorporating an estimate of workload (beds filled, outpatients treated) attributed to other conditions. This activity is then added to the SPM activity in order to allocate overhead.
Distance costs are important for the health system and individual patients, particularly in more remote areas of Indonesia where distances (measured in time or distance) between populations and facilities are large (due to oceans or mountains). The costing focuses on system costs and does not incorporate the costs to households of getting to a facility for initial treatment. These demand-side costs are important in explaining the difference between normative need and actual demand . The costing assumes that the system is responsible for patient transport between health centre and hospital where referral is medically necessary. The model incorporates a simple map that computes the straight line distance between all health centres and the district hospital(s). These distances are used to impute an emergency transport cost for patient transfers. This is clearly a simplification since transport links are not usually straight line. Furthermore some terrain may be more difficult (costly and slower) to travel on than others. This is particularly true where transport to a hospital necessitates crossing water. The costs derived, therefore, should be regarded as a minimum - local knowledge is required to augment the estimates. An extension of the model could incorporate more accurate time mapping based on GIS data.